Essentials of the Pediatric Exam
Essentials of the Pediatric Exam
Interviewing
• Interviews occur in different clinical
settings
– hospital admission
– outpatient clinic
• Preventive care
• Acute illness
• Follow-up
• Type of history should be according to
setting
Essentials of the Pediatric Exam
Interviewing
• Frequently the history is obtained from a
second party ( Parent)
• In older children, usually two sources of
information ( Patient and parent)
• Confidentiality becomes an issue in
adolescents
Essentials of the Pediatric Exam
Additional History
• Past history should include
– Neonatal history, including birth weight,
gestational age, maternal complications, alcohol
or drug exposure, and problems in the newborn
period
– Immunization status
– Development
– Diet
Essentials of the Pediatric Exam
Additional History
• Family History should include:
– Number and ages of siblings, consanguinity,
known genetic disorders, early childhood
deaths, cardiovascular disease, depression and
alcohol abuse
Essentials of the Pediatric Exam
Additional History
• Social History should include:
– Assessment of the home environment-type of
dwelling, water source, pets, resources
– School and peer relations important in schoolaged children and adolescents
Essentials of the Pediatric Exam
Additional History
• Adolescent History should include:
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Sex
Drugs ( Tobacco and ETOH as well)
Rock and Roll ( Peer relationships)
Family
School performance
Essentials of the Pediatric Exam
Physical Exam
• Establish rapport in an age appropriate
manner
• Order of exam changes with age
• Observation of the child gives additional
information
Essentials of the Pediatric Exam
Physical Exam
• General Appearance
– Recognize signs of acute illness by looking at
skin color, hydration status, respirations, mental
status, cry, social interaction
– Important to look at behavior, development,
body habitus, relationship to parent and
examiner
Essentials of the Pediatric Exam
Physical Exam
• Vital signs
– Heart rate, Respiratory rate, Blood pressure and
temperature
• Understand that normal values change with
age
Essentials of the Pediatric Exam
Physical Exam
• Measurements
– Height, weight, head circumference
(particularly in first two years)
– Plot data
– Note relationships between measurements
– Use of longitudinal data
Essentials of the Pediatric Exam
Physical Exam
• HEENT
– Fontanelles
– Head size, shape, hair whorls, etc. dysmorphic
features
– Eye exam
– Tympanic membranes- use of pneumatic
otoscopy- In toddlers, should be examined last!
– Oropharynx- look at teeth as well
Essentials of the Pediatric Exam
Physical Exam
• Neck
– Lymph nodes
– Know that nodes are more prominent in
childhood
– Test for nuchal rigidity and when they are
reliable
– Pits, clefts, tags, cysts
Essentials of the Pediatric Exam
Physical Exam
• Chest
– Know that normal respiratory rate changes with
age
– Abdominal breathing is normal in infants
– Look at rate and effort of breathing
– Distinguish stridor, wheezing, rales
– Distinguish transmitted upper airway sounds
Essentials of the Pediatric Exam
Physical Exam
• Cardiovascular
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Pulses
Heart rate, rhythm, quality of heart sounds
Murmurs- very common
Rate changes with age
Essentials of the Pediatric Exam
Physical Exam
• Abdomen
– Should be able to feel liver edge, kidneys in
newborn
– Umbilical cord in newborn
– Be able to evaluate for distention, tenderness,
rebound, masses
– Rectal exam- when indicated
Essentials of the Pediatric Exam
Physical Exam
• Genital exam- Inspection should be part of
every well child exam
– Recognize normal appearance of male and
female
– Tanner staging
– Need chaperone ( other than parent) present in
adolescents
– Parents may chaperone for younger children
and infants
Essentials of the Pediatric Exam
Physical Exam
• Extremities
– Importance of hip exam in newborns ( up to 6
months of age)
– Evaluate gait
– Recognize arthritis
Essentials of the Pediatric Exam
Physical Exam
• Spine/Back
– Be able to evaluate for scoliosis
– Look at back of every patient
Essentials of the Pediatric Exam
Physical Exam
• Neurologic exam
– Primitive reflexes
– Tone, strength, reflexes, importance of
symmetry
– developmental assessment helpful
– Much of Pediatric neuro exam can be by
observation
Essentials of the Pediatric Exam
Physical Exam
• Skin
– Recognize jaundice
– Be able to describe a rash- macular, vesicular,
papular, petechial, etc.
– Skin turgor- difficult to assess in young infants
Case Studies
• You are examining a 15-month-old
female who presents for a well child
examination. You have been talking with
her mother and are preparing to
examine the child. As your approach the
patient with your stethoscope, she starts
to scream.
• What do you do next?
Case Studies
• You are seeing a 6-month-old male who was
brought to clinic by his mother because of
fever. He is afebrile on arrival to clinic. His
history is significant for a 3 day history of clear
runny nose with the onset of fever earlier today.
His mother is concerned because he has been
pulling on his ears. During the physical
examination, the child is crying. The
examination is unremarkable except for
translucent but erythematous tympanic
membranes with normal appearing bony
landmarks. What diagnoses should you
consider?
Case Studies
• A 4-year-old male is brought to clinic for
a preschool check-up. He has been
healthy and has no complaints
presently. His physical examination is
normal but you are unable to see the
tympanic membranes secondary to
cerumen in the canals. You are unable
to remove the cerumen with a curette.
• What should you do at this point?
Case Studies
• A 16-year-old female is brought to clinic by her
mother because of poor school performance. She
has been your patient since the age of 3 years and
has had no significant health problems or previous
problems in school. Her mother expresses concerns
about her choice of friends and her lack of interest in
school. She rolls her eyes and denies that there are
any problems at school. However, she refuses to
answer other questions and does not make eye
contact with you.
• What would you do at this point?
Case Studies
• A 1-year-old boy is brought to clinic by his mother
who is concerned because he has been “lethargic”
and “irritable” for the last two days. He has a
temperature of 102 F. on arrival to clinic. When you
enter the room, he is lying in his mother’s lap but sits
up when you walk into the room.
• What observations may help you determine the
severity of this child’s illness?
Advice to the Novice
• Never show the fear in your eyes. They can
sense it.
• Try to spend time playing or interacting
with children before interacting with them
clinically.
• Don’t come on too strong. Spend some time
in the room with a toddler before addressing
or touching them.
• If they cry, don’t take it personally.
Advice to the Novice
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Wash your hands.
Wash your hands.
Wash your hands.
Wash your hands.
Wash your hands.
Wash your hands again.